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0 OPHTHALMOLOGY
Last Revised: APR 15 Last Reviewed: APR 15
12.1 CATARACT
Last Revised: APR 15 Last Reviewed: APR 15
AEROMEDICAL CONCERNS: Cataracts reduce visual acuity (VA). When the cataract involves
the visual axis, visual acuity is most affected in bright sunlight and conditions of glare.
WAIVER: The condition is considered disqualifying. Once vision has deteriorated to less than
20/20 correctable or the patient has a positive Glare test, the flier should be disqualified from
flying until successful surgical removal of the cataract. Waiver to SG1 may be considered after
surgery provided the VA returns to 20/20 corrected, is within refraction limits, and the Glare test
is negative (normal).
INFORMATION REQUIRED:
1. Ophthalmology consultation is required for initial waiver request.
2. Because of the potential for deterioration, ophthalmologic follow-up may be needed
every 6 months until surgery is deemed necessary.
3. Prior to and after surgery, a Mentor Brightness Acuity Test (BAT, a glare-testing device)
should be performed with VA documented for each eye separately at the low, medium
and high settings.
4. Confirmation is needed of exclusion of underlying pathology such as Wilson's disease,
diabetes or hypoparathyroidism.
TREATMENT: Surgery with an intraocular lens (IOL) implant usually provides a sufficiently
acceptable VA result for military flying duties. Consultation with NAMI ophthalmology prior to
surgery is recommended.
DISCUSSION: The visual effect of a cataract depends on its encroachment on the visual axis
and the proximity to the nodal point. A posterior subcapsular cataract can have a devastating
effect on vision. 2 to 3 episodes of serious dehydration can increase the risk of developing a
cataract 21 fold. Surgical success of greater than 90% in achieving a 20/40 best corrected VA
after 1 year has been reported. The RAF restricts the flying of personnel with IOL from high
performance aircraft and helicopters. This is because of the risk of pressure on ciliary body
blood vessels under high Gz or vibration and because of the unknown long term effect on the
corneal epithelium.
AEROMEDICAL CONCERNS: Color vision is required to accurately identify warning lights and
color visual displays in the cockpit, airfield and shipboard lighting, colored smoke in combat,
ground target identification, and aircraft formation lights. Interactions with other optical devices,
such as laser eye protection glasses and protective visors may worsen color vision problems.
For testing purposes, proper instructions and lighting are critical to accurate results. Best
corrected spectacles are recommended, but no tinted or colored lenses may be worn during
testing, as that will decrease the sensitivity of the test for detecting color vision deficiency.
WAIVER: Applicants are CD, no waiver if the applicant cannot pass the required color vision
tests. Certain non-aviators require adequate color vision, including ATC, UAV, and sonar
display operators (anti-sub aircraft). Waivers have been granted for aeromedical and other
Class II aircrew applicants on a case-by-case basis. Waivers for designated personnel with a
change in color vision may be considered on a case-by-case basis.
COLOR TESTS:
1. Pseudo-Isochromatic Plates (PIP) are considered a primary test of color vision.
Approved: Ishihara 38-plate edition, Pseudoisochromatic Ishihara Compatible
(PIPIC) 24-plate edition, ColorDx Standard 24-Plate Edition.
a. Scoring: 12 (or more) of 14 correctly identified red/green numerical test plates
constitute a passing score. Passing criteria is 12 or more plates correctly read, i.e.,
no more than 2 errors.
b. Use one demonstration and 14 test plates (the orange number on page one is a
demo plate only, and not a test plate, and should not be counted). Directions: Best
corrected vision, Daylight Illuminator stand or a light source ~ 6500 degree Kelvin
temperature “Daylight” fluorescent bulb, three seconds each page, no tracing
allowed, random order. Regular white incandescent bulbs may not be used, as they
are the incorrect color and reduce the sensitivity of the test.
c. Other editions of pseudoisochromatic plates may not have the correct types of plates
(numbers only required). Research has shown that individuals scoring 11 (or less)
on the PIP test do not have normal color vision.
2. Farnsworth Lantern (FALANT), The Farnsworth Lantern was designed in the 1940’s to
pass mildly color vision deficient individuals for Naval submarine service. Passing the
FALANT does not ensure normal color vision. Original model or modern Optec 900
accepted. Certain aviation classes may not use FALANT (per MANMED).
a. Passing criteria for FALANT remains 9 of 9, or 16 of 18 correct responses.
Directions: normal room lighting, best corrected vision worn, both eyes open, 8 foot
test distance, random presentation of targets, two seconds each target. Prior to
testing, read the instructions to the patient exactly as written on the side of the unit to
ensure predictable responses, and follow all directions on the guide.
b. The FALANT will be phased out eventually from all classes, but those designated
and student aviators who have passed the FALANT prior to phase-out will be grand-
fathered for their career, unless a documented color vision degradation requires
further evaluation to exclude progressive or acquired disease.
3. Computerized Color Vision Tests (CCVT) may be either used as a primary test of
color vision, or may be used as a backup test for PIP or FALANT failures.
INFORMATION REQUIRED: If a designated crewmember fails the PIP, and either a FALANT
or computerized test (worse than mild defect), an ophthalmologic evaluation is required to
screen for acquired pathology. Additionally, a practical test of color vision must be performed,
and administered with the objective oversight of the flight surgeon, type standardization
instructor, and type NATOPS officer as observers. Tests would include identification of cockpit
lighting, gauges, safety indicators, cockpit display symbology, map symbology for both cockpit
and actual charts (hazards/obstacles, airspace coordination areas, route markings, etc.),
identification of shipboard and landing field lighting, and ALDIS lights. For Marines, smoke color
identification testing is also required. A control group of two additional aviators with normal
color vision is recommended for comparison. Commanding Officer endorsement is required.
TREATMENT: N/A.
DISCUSSION: Defective color vision is overwhelmingly congenital, and mainly involves red and
green cones, due to X-linked genetics. Blue cones are encoded on Chromosome 7. In
Caucasians, approximately 8% of males have inherited red/green color defective vision. Of
males, 2% of the population have only two cones, “dichromats”, and are severely deficient.
The majority of color deficient individuals have three cone types, “trichromats”, but are red or
green weak. Moderate to severe color deficient individuals have increased difficulty interpreting
VASI and PAPI lights' correctly, as well as difficulty with navigation and shipboard lighting and
colored smoke identification. Color deficient individuals also take a longer time to interpret color
signals and targets, while also making more errors, than individuals with normal color vision.
Blue color deficiency may be acquired by ocular diseases, including cataracts, optic neuritis,
macular degeneration, central serous retinopathy, or side effects of medications or toxins.
Mild color vision deficiencies are considered acceptable for safe flight. Moderate-to-severe red-
green abnormalities are the most problematic for aviation, and those individuals can sometimes
pass the FALANT. Any degree of color vision deficiency, even mild, should always be
considered as a potential causal or contributing factor in mishap investigations.
ICD-9 CODES:
368.5 Color Vision Abnormalities
WAIVER: A waiver for visual acuity less than standards may be considered in designated
individuals, provided the central and peripheral retina is normal and all other visual standards
are met.
Consider whether a waiver is actually required. An aviator whose vision is worse than 20/400
will need a waiver to fly in any Service Group. A clear justification is required, including primary
type of aircraft in which he or she will be flying and the number of hours in that type of aircraft.
INFORMATION REQUIRED:
1. Optometry or ophthalmology consults for any waiver request for excessive refractive
error.
2. Ophthalmology consult required for cases of decreased visual acuity not due to simple
myopia, hyperopia, astigmatism or presbyopia (i.e. amblyopia, optic neuritis, corneal
scarring, cataracts, etc.)
3. Obtain dilated retinal evaluation at corrections greater than -8.00 diopters.
4. Progressive astigmatism should be evaluated to exclude keratoconus.
TREATMENT: Refraction by spectacles within the limits set by MANMED Chapter 15. Contact
lenses are permissible for aviation personnel after optometry examination, but spare clear
spectacles must be carried in flight and the aviator must demonstrate 20/20 with contact usage.
Other corneal surgical procedures (not allowed by Chapter 12.15) are CD, no waiver.
DISCUSSION: Myopia is usually a progressive condition, stabilizing around age 30. Significant
myopia is complicated by considerable visual distortion at the periphery of corrective lenses.
Individuals with significant myopia may see halos or flares around bright lights at night and are
more at risk for night blindness. Elongated globes are at an increased risk of retinal detachment
and lattice degeneration. Whenever a prescription is changed, aircrew should be warned about
transient visual distortion and counseled on the period of adjustment. Evidence suggests that
there is no difference in civil accident rates or in Naval carrier landing accidents in pilots who
require visual correction. Severe myopia tends to be a problem pertaining to Class II personnel
since the entry requirements for other pilots tend to be sufficiently stringent to exclude those
whose vision would deteriorate that much. The risk of retinal detachment in normals is 0.06%
ICD-9 CODES:
367.9 Decreased Visual Acuity
367.9 Ametropia [Includes Myopia and Hyperopia]
367.95 Ametropia, exceeding standards
368.0 Amblyopia
AEROMEDICAL CONCERNS: Although many visual cues regarding the relative positions of
objects in space (depth perception) are monocular. The binocular visual reflex of stereopsis is
an important indicator of normal visual acuity in each eye, with normal ocular alignment and
neurological function. Defective stereopsis may make certain piloting duties such as formation
flying and aerial refueling more difficult and unsafe.
WAIVER: No waivers shall be recommended for any candidate or designated Class I duty
involving actual control of aircraft. Class II and III personnel must meet standards for depth
perception except when remarked as "not required" under types of aviation duty specified under
MANMED Articles 15-87 through 15-99.
INFORMATION REQUIRED:
1. Valid tests of stereopsis include:
a. Armed Forces Vision Tester (AFVT)
b. Stereoacuity Plates used with polarized viewers such as the Stereo Optical, Titmus
Optical Stereo Fly, or Randot. A randomized version of these tests should be used.
c. Verhoeff Stereopter: tested at 1m, eight correct of eight random presentations for
passing grade.
2. A pass of any one test meets the stereopsis standard. The tests must be administered
and results recorded as specified in MANMED and elsewhere in the ARWG.
3. Recent loss of stereopsis in a designated Class I naval aviator is usually due to a
change in refraction or onset of presbyopia, but may also be a sign of cataract, macular
or optic nerve disease, or new motility disturbance, requiring ophthalmologic or
optometric evaluation. New failures to meet the stereopsis standard must be evaluated
by an ophthalmologist including completion of the ocular motility worksheet (See chapter
12.14).
DISCUSSION: Defective stereopsis is typically innate and due to abnormal visual development
prior to the age of 9. The Verhoeff Stereopter tests stereovision in real space. Eight test
presentations are made at a 1 meter distance, with no head movement of the patient. All eight
tests must be correct for a passing score. Causes of defective stereopsis include abnormal
ocular muscle balance, amblyopia, anisometropia, microtropia, and monofixation syndrome.
ICD-9 CODES:
368.33 Defective Depth Perception
AEROMEDICAL CONCERNS: Single, fused, simultaneous binocular vision in all versions at all
times with the stereopsis reflex active is a requirement for safe and effective duty involving
actual control of aircraft. Congenital or acquired defects of ocular alignment as well as any
surgery to correct ocular misalignment can cause mild to severe degradations to binocular
vision and acuity and be a grave hazard in aviation.
WAIVER: History of strabismus surgery is considered disqualifying for all aviation duty. A waiver
will not be considered for an SNA applicant, due to the risk of progressive degradation to
alignment even decades later. A waiver for aviation duty other than an SNA applicant will be
considered on a case-by-case basis no sooner than six months after a successful and stable
strabismus surgery if post-operatively, the member otherwise meets the visual standards
appropriate for his or her duty.
INFORMATION REQUIRED:
1. Submission must include an ocular motility worksheet (see chapter 12.14) completed at
the time of waiver request by a provider qualified to measure all required data.
2. Include copies of all eye exams and operative report(s) with AMS.
TREATMENT: Strabismus surgery involves enhancing or retarding the action of one or more
extraocular muscles in either or both eyes. An extraocular muscle tendon may be shortened
(resection) to strengthen its action, or the insertion of the muscle moved posteriorly on the globe
(recession) to weaken its action. Suspending the tendon on hangback sutures is an alternative
to traditional recession surgery. Adjustable sutures may be employed to fine tune ocular
alignment in the perioperative period. A spacer may be inserted in the muscle tendon with
unusual forms of vertical muscle surgery. In general, vertical muscle strabismus surgery is
more complex and problematic than horizontal muscle surgery for simple eso- or exotropia.
DISCUSSION: Ocular misalignment is always the consequence of disease and never a normal
finding. Surgery on extraocular muscles is imprecise and has a risk of regressing to the original
state of misalignment or progressing in effect and causing sequential overcorrection. Multiple
surgeries are frequently necessary for congenital misalignment. Scarring of the globe and
adnexa after muscle surgery may lead to restricted ocular movements. Vertical muscle surgery
often causes or does not fully correct cyclotorsional misalignment.
Realignment of the eyes with muscle surgery does not resolve the underlying disorder in
congenital misalignments and while peripheral binocular function may be partially enhanced,
normal central binocular stereopsis is rarely achieved. Even after satisfactory surgical
alignment in congenital esotropia, residual comorbidities such as latent nystagmus and
dissociated vertical deviations are often seen. The desirable cosmetic result after strabismus
surgery is 10 or fewer prism diopters of misalignment, since this relatively small degree of
heterotropia is not noticeable to casual observation of the eyes. Asymptomatic vision (i.e.
normal acuity without diplopia complaints) with tropia less than 10 prism diopters, meets the
NOHOSH standard for Class II and III.
ICD-9 CODES:
H153 Surgery for strabismus or ocular muscle imbalance
INFORMATION REQUIRED:
1. Evaluation by a qualified optometrist or ophthalmologist is necessary.
2. The consult should address any history of diplopia or previous eye surgery, and include
all the studies requested on the accompanying ocular motility worksheet (see chapter
12.14)
ICD-9 CODES:
378.4 Excessive Phorias
378.41 Esophoria
378.42 Exophoria
378.43 Hyperphoria
AEROMEDICAL CONCERNS: A detached or torn retina can lead to visual impairment, the
degree of which depends on the part of the retina involved and the success of any timely
surgery. Some retinal repairs involve injecting gas into the eye (pneumatic retinopexy), which
will restrict the patient from air transport for some time afterward.
Routine exposure to slow-onset G forces has not been shown to increase the risk of retinal
detachment.
Small atrophic peripheral holes generally do not require treatment, but should be monitored for
progression or subretinal fluid development over time by annual dilated examinations.
WAIVER: Waivers will not be considered in SNA applicants for retinal detachments involving
intraocular repairs, vitrectomy, pneumatic retinopexy or sclera buckles. SNA applicants with
small peripheral tears and/or detachments treated successfully with laserpexy may be
considered on a case-by-case basis after six months with stable follow-up examinations.
Waivers in other designated classes will be considered on a case-by-case basis after a
minimum of three months post-operatively. Annual dilated exams will be required for any
waivered retinal tear, treated holes or detachment. A Grounding physical is required to be
submitted upon diagnosis due to the post-operative observation period of greater than
60 days.
INFORMATION REQUIRED: Please submit all relevant eye examinations and operative reports
to include a Humphrey Visual Field, detailed retinal drawings, motility exam (if scleral buckling is
performed), and glare testing if a pneumatic retinopexy (air injection) or vitrectomy is performed.
TREATMENT: Surgical intervention is required in most cases. The best approach will be
determined by the surgeon and may consist of one or more of the following techniques
cryotherapy, laser retinopexy, pneumatic injection, scleral buckling, or vitrectomy.
DISCUSSION: Visual acuity and visual field loss, changes in refractive error, motility disorders,
and cataracts are frequent sequelae for retinal detachments. Detachments involving the macula
have the highest impact on central vision. Annual follow-up is required for the duration of
military service and recommended after separation from service.
ICD-9 CODES:
361.0 Retinal Detachment with retinal defect
Open angle glaucoma is the most common type and is usually asymptomatic, even as vision
loss is occurring slowly. Gradual, almost imperceptible loss of peripheral visual field is typically
the earliest clinical manifestation with loss of central vision occurring only in the most advanced
later stages of the disease. Elevated eye pressure is not always present in patients losing vision
from open angle glaucoma. Roughly a third of those presenting with glaucoma have intraocular
pressures (IOPs) less than 22 mmHg and some will continue to lose vision even with a lowering
of their IOP with eyedrops or surgery.
Acute angle glaucoma is much less prevalent and will present in a much different manner then
the open angle variety, with symptoms such as acute onset of eye pain, decreased vision, and
halos around lights. Signs may include a red eye with a hazy cornea and a mid-dilated, poorly
reactive pupil.
Both types require referral to the eye clinic with an acute angle attack requiring emergency
referral to an ophthalmologist to reduce the risk of swift and severe vision loss. Both types of
glaucoma are considered disqualifying because the risk of loss of vision and peripheral visual
fields is incompatible with flight duties.
Ocular hypertension (i.e. elevated pressures in the eye, without visual field loss, or optic nerve
cupping) is not equivalent to the actual diagnosis of “glaucoma”. In fact, most people with what
is often considered to be high pressure (>22 mm Hg) never develop vision loss. This
population, nonetheless, is at higher risk of developing glaucoma and so this condition is also
considered disqualifying.
WAIVER: For the purposes of Naval Aviation, any IOP consistently (on at least 2 different
exams on different days) and accurately measured above 22 mmHg by contact tonometry
(applanation tonometer or tonopen), is considered disqualifying whether or not the diagnosis is
simply ocular hypertension or glaucoma. Simply large optic nerve cupping alone is not
disqualifying, if all other glaucoma screening tests and intraocular pressures are normal.
Applicants: Waivers will not be considered for actual glaucoma, or ocular hypertension
(corrected for corneal thickness or pachymetry measurements).
Initial Evaluation:
A complete eye exam must include the following:
1. IOP by Goldmann applanation tonometer or Tonopen
2. Central Corneal Thickness (pachymetry)
3. Dilated fundus examination (to include comment on the cup-to-disc ratios and
description of the nerves)
4. Automated visual field testing (30-2 or 24-2 SITA, standard or fast protocols are
acceptable, ensure reliability of the test, and repeat any abnormal field examinations,
submit ALL testing)
5. Slit lamp examination
6. Gonioscopy grading reports on the angles of the eye
7. Retinal nerve fiber layer analysis (i.e. ocular coherence tomography or OCT) is required.
TREATMENT:
The following are acceptable topical agents and non-invasive treatments:
1. Prostaglandin analogs are the initial treatment of choice due to insignificant incidence of
systemic side effects.
2. Beta blockers – side effects of reduced exercise tolerance, orthostatic hypotension and
loss of G-tolerance.
3. Carbonic anhydrase inhibitors – side effects of tingling in hands and feet, depression,
anemia and sluggishness.
4. Sympathomimetic eye drops – side effects of hypertension, tremors, tachycardia,
headache, conjunctivitis, anxiety.
5. Laser treatments to the angle of the eye (selective laser trabeculoplasy or SLT) may
reduce the intraocular pressures for up to five years, and may reduce or eliminate the
need for eye drops during this time. Re-treatment may be necessary, and routine follow-
ups must be maintained.
Beta blockers and carbonic anhydrase inhibitors must NOT be used if there are any significant
side effects, including any reduction in circulatory or respiratory function. The treating eye care
professional must be mindful of the unique cardio-respiratory demands of the aviation
environment, and may need input from the flight surgeon to tailor any medications. Patients
must be instructed in proper drop protocols to reduce systemic absorption (e.g. pinching the
lacrimal sac for two minutes to reduce migration to the nasal mucosa. Miotic drugs are
incompatible with night operations due to the inability of the pupil to dilate to admit sufficient
light.
DISCUSSION:
Waivers may be considered if peripheral visual field loss is minimal, and IOP is stabilized either
with an acceptable topical agent as listed above or with laser trabeculoplasty. Incisional
surgery, including filtration or tube shunt surgery is usually not considered compatible with safe
flight operations. Continuation of the waiver requires annual submission, though eye
examinations are usually conducted more frequently as determined by the treating eye doctor.
WAIVER: Waivers will not be considered for applicants, but may be considered in designated
personnel if correctable to 20/20 with spectacles.
Local boards of Flight Surgeons are not appropriate for this diagnosis.
TREATMENT: Contact lenses are often necessary to achieve the best vision. Advanced
disease management may include a full-thickness corneal transplant, which is not waiverable.
Corneal refractive surgery is an absolute contraindication in the presence of any keratoconus.
Contact lens use in any aviator requires specific authorization on the aeromedical clearance
form (up-chit). Please refer to section 12-16, Naval Aviation contact lens policy.
DISCUSSION: It is very difficult to diagnose keratoconus in the early stages unless a corneal
topographic mapping apparatus is used. Aviators with rapidly increasing myopia or astigmatism
may warrant such testing.
Keratoconus is usually bilateral but in rare cases, may affect one eye only. The symptoms
usually start in the teen years. The condition is slowly progressive in 20%-25% of cases, but
stabilization can occur at any time.
ICD-9 CODES:
371.6 Keratoconus
WAIVER: A history of ODD is considered disqualifying for all aviation duty. Due to the
possibility of progressive visual field loss, a waiver will not be considered for applicants. Waivers
may be considered in already designated personnel providing the member has no other optic
pathology, significant visual field loss, and otherwise meets the visual standards appropriate for
his or her duty.
Local Boards of Flight Surgeons are not appropriate in this situation since waivers are
considered on a case-by-case basis.
INFORMATION REQUIRED:
Initial Evaluation:
1. Ophthalmology consultation is required for initial waiver request to confirm the diagnosis
of ODD and the absence of other conditions (e.g. papilledema).
2. Complete aeromedical history to include pertinent positives and negatives (e.g.
headaches, pulsatile tinnitus, hypertension, diabetes, family history of ODD).
3. Document presence or absence of visual symptoms and their operational impact (e.g.
transient visual obscurations, perceived scotomas or metamorphopsia).
4. Documented exam to include stereoscopic optic disc evaluation, refraction to best visual
acuity, color vision and Amsler grid testing.
5. Optic disc photos should be obtained for baseline documentation and future monitoring.
6. Automated perimetry visual field testing (Humphrey 30-2 is preferred, but 24-2
acceptable).
7. Retinal nerve fiber layer (RNFL) analysis using Optical Coherence Tomography (OCT) is
required for baseline and future monitoring.
8. B-scan ultrasound (preferred) or CT to demonstrate buried drusen.
TREATMENT:
None. No evidence or definitive studies exist at this time supporting surgical intervention.
DISCUSSION:
Optic Disc Drusen is an indolent and progressive condition, with studies showing as high as
75% of those with ODD developing visual field abnormalities. Central vision may be affected
with rare cases of anterior ischemic optic neuropathy or retinal bleeding from choroidal
membranes. A thorough, detailed history and a comprehensive eye exam are essential to
ensure that the individual has optimal nerve function. While the risk for sudden incapacitation
Candid reporting of any change in visual performance by the aviator is as important as objective
annual Amsler grid and visual field testing to ensure the safety of flight and mission readiness.
ICD-9 CODES:
377.21 Optic Disc Drusen
AEROMEDICAL CONCERNS: Symptoms vary and range from mild peripheral visual blurring to
severe central vision loss. Onset is usually painless with rapid onset of vision symptoms within
minutes to hours.
INITIAL WAIVER:
1. All ophthalmology consultation notes from time of first diagnosis and subsequent visits
documenting treatments and visual recovery to normal.
2. Retinal photos of baseline disease and post-treatment retina. Submit copies of any
fluorescein angiography (FA) performed at the time of initial presentation, and any
subsequent FA.
3. Exclusion of other pathology such as hypertension, diabetes, blood dyscrasias, multiple
myeloma and dysgammaglobulinemia is required.
ANNUAL WAIVER:
1. Ophthalmology consultation required, with retinal photos, drawings and all other
documentation showing stability of the disease and vision.
DISCUSSION: Macular edema occurs in 57% of cases of occlusion of the temporal branch of
the retinal vein. Visual acuity improves in 60% of patients with branch retinal vein occlusion and
50% achieve visual acuity of 20/40 or better within 1 year. In central retinal vein occlusion,
neovascular glaucoma develops in 15% of cases.
ICD-9 CODES:
362.3 Retinal Vein Occlusion
WAIVER: A waiver can be considered for a single episode of iritis that resolves without
complication and is not associated with any underlying systemic condition. A waiver will not be
considered for recurrent uveitis of any type, or for any posterior uveitis, in applicants. Any
associated underlying diagnoses should be considered carefully when determining waiverability
for designated persons.
INFORMATION REQUIRED:
1. Ophthalmology consult is preferred, with dilated fundus examination to exclude posterior
disease. Iritis history to rule out other causative diseases. Recurrent episodes will
require laboratory workup for underlying autoimmune or infectious disease.
2. Appropriate referral as necessary for any underlying systemic condition.
TREATMENT: Treatment for uveitis depends on the portion of the uvea that is affected.
Anterior uveitis is usually successfully treated with topical steroids and cycloplegics to reduce
pain and ciliary body spasm.
DISCUSSION: Uveitis is an inflammation of the uveal layer inside the eye. The uvea consists
of the choroid, ciliary body, and iris. It provides most of the blood supply to the retina. Uveitis
may be unilateral or bilateral and occurs most frequently in people ages 20-50.
Iritis is the most common form of uveitis. These patients have an intense dull pain of the
eye, perilimbal injection and extreme sensitivity to light. The hallmark signs of anterior uveitis
are a constricted pupil on the affected side, and “cells and flare” in the anterior chamber.
WBC’s and proteins are liberated into the anterior chamber as part of the inflammatory
response. In more severe cases, patients may present with keratic precipitates (white blood cell
collections on the posterior corneal surface) and posterior synechiae (iris adhesions to the
anterior lens capsule). Most cases of iritis are idiopathic, but blunt trauma to the eye will
frequently be associated with iritis. Iritis may also be the result of an autoimmune disorder,
infection, or exposure to toxins. A single episode of iritis is generally not an indication for further
testing to determine a systemic cause, however, recurrent, or persistent iritis warrants further
work up.
Posterior uveitis is an inflammation of the choroid and/or ciliary body (inflammation of the
ciliary body, or pars planitis, is often termed intermediate uveitis, however, will be grouped with
posterior uveitis for the purpose of this discussion). Patients with this type of inflammation may
complain of ocular pain and/or floaters, however, are quite often asymptomatic. Comprehensive
slit lamp examination may reveal an inflammatory response (“cells and flare”) in the posterior
chamber. The severity of the response may result in a “snow banking” or “snowball”
appearance, and resultant scarring can form, leading to vision loss.
ICD-9 CODES:
364.3 Uveitis
WAIVER: Asymptomatic ptyergia up to and including 1.0 mm corneal invasion (measured from
the limbal border at the slit lamp) are NCD for both applicants and designated aviation
personnel, provided vision corrects to 20/20 with spectacles.
Designated aviation personnel with symptomatic pterygia or pterygia greater than 1.0 mm are
CD but a waiver will be considered if vision corrects to 20/20 with spectacles and symptoms, if
present, are controlled with conservative measures such as artificial tears. If a pterygium
requires surgical removal, a waiver may be considered when the member’s vision has stabilized
and is correctable to 20/20, post-op complaints have resolved, and the member is returned to
full duty by the operating surgeon. Aviation applicants with pterygia greater than 1.0 mm are
NPQ with waiver not recommended.
INFORMATION REQUIRED:
1. Ophthalmology or optometry consult to include:
a. Drawing or clear description of the pterygium and the amount of encroachment on
the cornea.
b. Manifest refraction documenting visual acuity corrects to 20/20 with spectacles.
c. Documentation of any symptoms (e.g. tearing, irritation, etc…) and any treatments.
2. Post-op patients also must also submit:
a. Operative report.
b. Clearance for full duty by operating surgeon.
c. Post-op manifest refraction documenting visual acuity corrects to 20/20 with
spectacles.
d. Documentation of absence of post-op complications or complaints.
ICD-9 CODES:
372.4 Pterygium
Habitual Rx OD_____________________
Cycloplegic OD___________________ 20/
Refraction
(as needed) OS___________________ 20/ OS_____________________
Far: R L Near R L
(all gazes) (all gazes)
Extraocular Motility Maddox Rod or Von Graefe Stereopsis (Verhoeff, Randot, or Titmus)
Prism Diopters Arcseconds
Rank/Rate Unit/Address
PERTINENT HISTORY: Explain why the workup is being done. For example: “scored 7 esophoria on
AFVT” or “muscle surgery OS at age 6 years.”
REFRACTION: SNA applicants need a cyclopentalate 1% cycloplegic refraction recorded, all others
require a manifest refraction only. SNA applicants who see less than 20/20-0 on the Goodlite
Chart unaided also require a manifest refraction recorded.
HABITUAL RX: Record the subject’s habitual Rx here if different from the manifest. If none is used, or
the subject wears contact lenses, please note on the form.
COVER TEST: Report numerical prism diopter values. Do horizontal and/or vertical as applicable to the
case. Horizontal limits are approximately 45 degrees to the left and right of center. Vertical limits
are approximately 25 degrees above and 35 degrees below center. Limits may need to be
modified as dictated by the size of the nose and brow.
MADDOX ROD/VON GRAEFE: Report numerical prism diopter values for both horizontal and vertical
phorias. Fixation target must be at 20 feet.
STEREOPSIS: Verhoeff, done at 1 meter in a normally lit room. Neither the device nor the patient
should move during the test. Randot or Titmus stereo testing acceptable, do not allow head
movement. Report in Arcseconds.
WORTH 4 DOT: Perform at both distance and near. Report “fusion,” “diplopia,” or “suppression OD (or)
OS.”
VECTOGRAPH: (If available) Test on the 20/40 (V O C S R K 4) line of the A.O. Vectographic slide.
Report any suppression, and which eye is suppressing. If there is no suppression, state so. If
not available, put “Not Available”.
RED LENS TEST: (If available – Required for USAF) Test all 9 position of gaze, just like the cover test.
Report any diplopia. If no diplopia is reported, state so.
4 BASE OUT TEST: This test is not always applicable and may be left blank if not used. Prism
introduced over either eye to look for suppression. Can augment the diagnosis of
microstrabismus.
NOHOSH = No Obvious Heterotropia or Symptomatic Heterophoria. Answer this question if the subject
is NPQ (Not Physically Qualified for SNA (Student Naval Aviator), but would consider applying for
the SNFO (Student Naval Fight Officer) program.
Acronyms/definitions:
NAMI: Naval Aeromedical Institute (Pensacola, FL)
AFVT: Armed Forces Vision Tester
SNA: Student Naval Aviator
SNFO: Student Naval Flight Officer
Verhoeff: Specialized manual stereo tester.
AEROMEDICAL CONCERNS:
Definitions:
Corneal Refractive Surgery (CRS): A laser is used to reshape the anterior corneal surface
reducing refractive error and reliance on spectacles or contact lenses. A “wavefront-guided”
(WFG) or “custom” procedure uses wavefront analysis technology, and may improve the visual
outcome of the procedure.
Laser in-situ keratomileusis (LASIK): A cornea stromal flap is created with a surgical blade or
infrared laser after which, an excimer laser is used to reshape the exposed corneal stroma. The
corneal flap is then repositioned. Pain is minimal and vision recovery is much faster than PRK.
All forms of refractive surgery are disqualifying for aviation duty, but waivers are readily
granted if the member meets all waiver guide policy guidelines. Designated members who
undergo refractive surgery shall be grounded at the time of surgery, but a grounding physical is
not required. Designated members shall not return to flight duty until a Local Board of Flight
Surgeons (to include one eye provider) recommends a waiver via an Aeromedical Summary
(AMS) and issues a ninety-day temporary aeromedical clearance notice.
Both PRK and LASIK are waiverable at this time (see specific sections below).
All other forms of refractive surgery, or any vision or corneal manipulation or surgery,
including RK (radial keratotomy), LTK (laser thermal keratoplasty), ICR (intracorneal ring), ICL
(intraocular corrective lens), and clear lens extraction, are permanently disqualifying
(CD/WNR) for all aviation duty Class I, II and III personnel. The prior use of orthokeratology
(rigid contact lens corneal reshaping) is NCD provided that it is permanently discontinued prior
to obtaining flight status and all appropriate refractive standards are met with stable topography.
Applicants only:
1. Applicants may not have more than 3D of pre-operative cylinder and 3.5D of pre-op
anisometropia, and must satisfy the above general guidelines, as well as the following
guidelines:
a. SNA applicants shall not exceed pre-operative refractive limits of +3.00 to -8.00
(SE) for either PRK or LASIK, and must additionally have a post-operative
cycloplegic refraction using cyclopentolate performed at a military installation.
b. Class II & III applicants: pre-operative refractive error shall not exceed +6.00 to
-8.00 (SE) for PRK or LASIK.
c. Civilian applicants must obtain PRK or LASIK at their own expense at a civilian
refractive surgery center. DoD instruction 6130.03, enclosure 4, requires a six month
minimum wait time before submitting LASIK or PRK waiver requests for civilian
accessions. All paperwork and operative reports must be available and submitted for
waiver consideration.
d. Active duty applicants with a normal and stable post-operative course who are
applying for aviation programs (i.e. STA-21, UAV operator, NFO/SNFO to SNA
transition, etc.), may be considered for waivers at 3 months, with due consideration
for all MANMED and ARWG policies and guidelines.
e. Active duty applicants may have astigmatism correction up to 6D of cylinder, per
FDA limits on the respective laser platform utilized. Programs leading to a
commission must still adhere to the 3D cylinder limit.
f. Active duty aviation students (SNA, SNFO, etc.) who are authorized to undergo
refractive surgery by the aviation training command may be considered for waivers at
1. A PRK waiver request may be submitted after the following wait periods:
a. myopia -6.00 diopters or less spherical equivalent (SE): 3 months
b. myopia greater than -6.00 diopters SE: 6 months
c. hyperopia SE: 6 months
2. A LASIK waiver request may be submitted after the following wait periods:
a. myopia correction up to -11.5D SE: 2 weeks
b. hyperopia up to +4D SE: 4 weeks
c. hyperopia greater than +4D SE and up to +6D SE: 8 weeks
3. If still requiring prescription topical medication (artificial tears, or cyclosporine drops
excluded) then restriction of flight activities to the local area is recommended.
4. Class I aviators, specifically, must undergo PRK or LASIK treatment at one of the USN
designated refractive surgery centers which have Navy ophthalmology staffing (includes
Tripler AMC, Keesler AFB, or Wilford Hall). Check for a current listing if considering a
non-Navy facility since staffing may change.
5. Class II, III, and other active duty flight personnel (e.g. UAV personnel, select
passengers) may undergo PRK or LASIK at any DoD refractive surgery center.
6. For PRK, pre-operative refractive limits are per the FDA limits for the particular refractive
laser platform utilized, for already designated personnel within their aviation class. For
LASIK, waivers may be granted for myopia up to -11.5D spherical equivalent (SE),
hyperopia up to +6.00D (SE), and up to 6D of cylinder (astigmatism correction).
7. For both PRK and LASIK, the PRK AMS template (available on the NAMI waiver guide
website) may serve as a Local Board of Flight Surgeons, requiring review and
endorsement by two flight surgeons, plus an eye care provider (military optometrist or
military ophthalmologist), and commanding officer cognizance. A ninety-day
aeromedical clearance notice may be issued at that time, pending BUPERS waiver
approval. Submit the AMS and waiver package immediately to NAMI to avoid
unnecessary delays in obtaining BUPERS final approval.
8. No deployment for at least three months following PRK and one month following LASIK
surgery (per NAVMED POLICY 08-008, dtd 10 JUN 2008). Post-operative operational
training requirements (such as CS gas, pepper spray, water survival training, etc.) may
be performed per ophthalmologist guidance.
Wavefront guided (WFG), or “custom” refractive surgery has been evaluated by the Naval
Refractive Surgery Center and yielded results that are superior compared to conventional
treatment. Based on this analysis, aviation personnel should undergo a wavefront-guided or
custom procedure, if at all possible. Some patients are not candidates for a wavefront-guided
treatment or LASIK for various reasons, and conventional or PRK treatment remain viable
options.
As with any surgical procedure, there are inherent risks, such as quality of vision deficits (e.g.
halos and glare at night), haze, flap complications and persistent eye discomfort (e.g. dry eye or
recurrent erosions). A detailed description of the risks, benefits, and alternatives should be
discussed and consented between the patient and their refractive surgeon.
Undergoing PRK or LASIK does not guarantee qualification for aviation. The member must
meet pre-operative standards in MANMED and this waiver policy guide. Post-operatively the
applicant must meet all MANMED vision standards appropriate to their aviation class.
When obtaining corneal refractive surgery it is incumbent upon the member and the member’s
commanding officer and flight surgeon to be aware of corneal refractive surgery waiver
recommendations at the time of the surgery and subsequent submission. Rapidly evolving
technology results in changes to waiver guidelines when appropriate. Every effort will be made
to publish new regulations widely, but the only valid source of current recommendations shall
remain the Manual of the Medical Department. When in doubt, NAMI ophthalmology remains
available for consultation through phone or email: 850-452-2933;
usn.pensacola.navmedotcnamefl.list.nami-ophthal@mail.mil
ICD-9 CODES:
P1177/H1177 PRK
P1171/H1171 LASIK
***NOTE: ICLs are NOT approved for any class of Naval Aviation, including Unmanned Aerial
System Operators.
Class I, Class II: The LASIK Study for designated Class I and Class II personnel has been
closed. Be aware that Class I personnel are required to have their LASIK procedure performed
at one of the DoN Refractive Surgery Centers (including Tripler AMC and Keesler AFB, which
have Navy ophthalmology support). Class II personnel may have LASIK performed at any DoD
refractive surgery center, being mindful of current refractive policy limits for waivers. For
designated personnel previously enrolled in the study, annual submission is required for
renewal with supporting documentation per the LASIK study protocol.
WAIVER: The LASIK Study for Student Naval Aviators Study has been closed to new enrollees;
but, LASIK is still waiverable for new candidates and students in all aviation classes. Contact
Information: usn.pensacola.navmedotcnamefl.list.nami-ophthal@mail.mil, Contact Phone: 850-
452-2933.
Discussion: “All-laser” LASIK is preferred, which utilizes two types of lasers: one to create the
LASIK flap and another to perform the corneal vision correction. The laser flap is preferred over
a metal keratome blade to reduce the risk of operative complications and enhance post-op
stability. “Wavefront-guided” or custom LASIK is preferable, if available, and the patient is a
candidate for such after evaluation by their surgeon. “All-laser, custom LASIK” gives a better
visual outcome over conventional treatments. This has been borne out by repeated Navy
research studies. Please note that no specific method of LASIK is mandatory for waiver
consideration, as long as all pre- and post-op criterion and vision standards are met in Chapter
12.15 of this waiver guide.
ICD-9 CODES:
P1171/H1171 LASIK
All classes of Naval aviation personnel shall be allowed to wear contact lenses during duty
involving flight when the following requirements have been met as outlined below, and allowed
by local commander’s policy in theater. A notation from the flight surgeon authorizing contact
lens use is required on the aeromedical clearance notice (up-chit) DD2992. Contact lens use is
not considered disqualifying (NCD). A waiver for their use is not required.
REQUIREMENTS:
1. Visual requirements specific to each class and service group must continue to be met
while wearing contact lenses.
2. Near visual acuity must be 20/20 in each eye. Presbyopic personnel may use spectacles
over their contacts to achieve this standard.
3. There must be no symptoms incompatible with safe flight, e.g. fluctuating vision,
reduction in vision at night or under glare conditions, or discomfort.
4. Must have worn contact lenses on a daily basis without complication for a minimum of
one month before their use can be authorized on the “up-chit”.
5. The prescribing eye doctor must note in the patient’s record that a good fit has been
achieved and that no further changes are planned.
6. SCLs are not to be worn overnight while in flight training or flight status unless
operationally mandated. If extended contact lens wear (greater than 24 hours) is an
operational requirement, lenses may be worn for a maximum of seven consecutive days.
Personnel are encouraged to limit extended wear to the shortest period possible. A
minimum 12 hour recovery period, during which no contact lenses are worn, shall follow
each extended wear period. Rigid gas permeable lenses shall not be used overnight.
7. During aviation duties, it is the responsibility of all contact lens wearers to carry clear
spectacles in a readily accessible protective case which correct the wearer's vision to all
applicable standards.
8. Follow-up examinations for personnel wearing contact lenses shall be conducted at least
annually by a Navy optometrist or ophthalmologist.
For any other questions regarding specific brands of contact lenses or waiver issues, please
contact:
Phone: NAMI Eye Department at 850-452-2933
Email: usn.pensacola.navmedotcnamefl.list.nami-ophthal@mail.mil
AEROMEDICAL CONCERNS: The condition can cause blurred vision, ocular itching, burning,
tearing/discharge, eyelid edema, and photophobia. These signs and symptoms, along with the
use of medications with unacceptable side effects, have the potential for in-flight incapacitation
and prolonged periods of grounding.
WAIVER: Chronic and perennial allergic conjunctivitis is CD for all applicants according to the
MANMED. Seasonal allergic conjunctivitis in designated personnel is NCD. The member shall
be grounded while symptomatic. A waiver is not required if the member is treated with an
approved medication. If the condition is associated with rhinitis, see chapter 6.1,
ALLERGIC/VASOMOTOR RHINITIS.
DISCUSSION: Two forms of allergic conjunctivitis are quite common: seasonal (SAC) and
perennial (PAC). SAC coincides with pollen blooms (e.g., ragweed, trees, grasses).
PAC may occur at any time or even year round (e.g., exposure to ubiquitous cat dander,
chemicals or dust). The most effective treatment is elimination or avoidance of the potentially
offending allergen, although this may not always be possible or practical.
Due to the potential chronicity of allergic conjunctivitis, long term use of medication may be
necessary to keep the member asymptomatic for aviation duties, including nasal and inner ear
functionality. The flight surgeon should be cognizant that the aviator or aircrew member may
have residual allergy symptoms such as itchy, tearful eyes, runny nose, sneezing, scratchy
throat and other allergic symptoms which would preclude flight until effectively treated.
Ophthalmic antihistamines and/or mast cell stabilizers have minimal side effects and are
approved for use in aviation personnel. Contact lenses may exacerbate the condition and
should not be worn until the member is asymptomatic.
ICD-9 CODES:
372.14 Chronic Allergic Conjunctivitis
372.05 Acute Atopic Conjunctivitis
WAIVER: CSR is considered disqualifying (CD). Waivers will not be considered for applicants
(CD/WNR), but may be considered for designated personnel. Evaluation by an optometrist or
ophthalmologist is required with an annual submission.
Local boards are authorized for initial cases of CSR once condition has resolved (cleared
by optometry/ ophthalmology), if less than 60 days has elapse since diagnosis, best
corrected visual acuity has returned to the aviator’s specific class standard, the aviator
is asymptomatic to visual disturbances, and no metamorphopsias are noted on Amsler
Grid testing. Recurrent cases of CSR require a new waiver to be submitted for review and
approved by NAMI for each new episode (no local boards authorized). A grounding physical
is required if more than 60 days has elapsed since diagnosis without resolution.
INFORMATION REQUIRED:
1. Slit lamp examination of the macula with 78/90 diopter fundus lens
2. Amsler grid, documenting any metamorphopsia
3. Optical coherence tomography reports (submit color scans: from diagnosis to resolution)
4. Humphrey Visual Field 10-2 (only required if laser treatment was performed)
5. Fluorescein angiography (optional, at the discretion of the treating ophthalmologist,
submit if performed and photos available)
TREATMENT: CSR is self-limiting with a good prognosis. Eye exams should be performed
every 4-6 weeks until the condition has resolved and vision has stabilized and returned to
baseline. Ocular coherence tomography should be performed upon diagnosis and after
subjective/objective findings have resolved. In certain cases, laser photocoagulation may be
considered to enhance recovery, but may leave a small permanent blind spot.
DISCUSSION: Central serous retinopathy can be visually debilitating to a patient’s central vision
and results in normal to decreased visual acuity ranging from 20/25 to 20/200. This condition
usually occurs in males (10:1), 20 to 50 years old, and is associated with type-A personalities
and increased stress levels. Typically patients recover visual acuity, but a small percentage of
patients may not return to 20/20. Resolution usually occurs over a course of 4-6 months, with
continuing improvement in visual acuity over 24 months. Prognosis is worse for patients with
recurrent or prolonged disease. Laser photocoagulation may be considered for occupational
reasons, if CSR occurs in the contralateral eye, or if no resolution has occurred in more than 6
months. Laser intervention may shorten duration by up to 2 months, but typically has no effect
on the final visual acuity outcome.
ICD-9 CODES:
362.41 Central Serous Retinopathy
Waivers are considered for designated personnel if intraocular pressure (IOP) is 22 mmHg or
less in each eye, taking into account corneal thickness (corrected IOP), with no more than 4
mmHg difference between the eyes, normal Humphrey 24-2 visual fields, no glaucomatous
changes present in the optic disc, and no treatment (pressure lowering drops/laser) is indicated.
Local boards are authorized for designated personnel with normal corrected IOP, as long
as no treatment is indicated, and no signs of glaucoma are present on ophthalmologic
examination (normal visual fields, normal optic nerve appearance).
Waiver submission is required on a routine basis. If the corrected IOP is above 22 mmHg, then
annual submission with a complete glaucoma screening is required. If corrected IOP
measurements are above 22 mmHg by applanation tonometry on two separate occasions, or if
laser/medical treatment is required for management of PDS, then the diagnosis should be
converted to pigmentary dispersion glaucoma (PDG - see Glaucoma chapter 12.8).
INFORMATION REQUIRED:
Initial Waiver:
1. Eye exam by a Navy optometrist or ophthalmologist
2. IOP measurement by applanation tonometry (Goldmann)
3. Central corneal thickness measurement (Pachymetry) with IOP correction factor
4. Automated visual field (24-2 SITA)
5. Optic nerve evaluation with comment on health of neural rims, with color disc photos
uploaded into AERO
6. Slit lamp examination with comment on anterior segment findings related to PDS
7. Gonioscopy to document trabecular meshwork pigmentation
Waiver Continuance:
1. Eye exam by a Navy optometrist or ophthalmologist.
2. IOP measurement with applanation tonometry (Goldmann)
TREATMENT: Besides annual monitoring of PDS, treatment is usually not initiated if IOP is 22
mmHg or less, and there are no signs of glaucomatous changes. However, any glaucomatous
changes or elevation of IOP may cause the eye provider to recommend pressure-lowering
medications or laser treatments (See Glaucoma chapter, 12.8 for discussion on waivers for
glaucoma).
DISCUSSION: Pigment dispersion syndrome (PDS) is a bilateral condition that typically occurs
in young adult males (2:1) under the age of 45. PDS is characterized by liberation of pigment
granules from the posterior iris, depositing in the anterior chamber structures. It can appear
asymmetric between the eyes.
Deposition of this pigment occurs on the posterior corneal surface (‘Krukenberg spindle’ on the
endothelium) and in the anterior chamber angle trabecular meshwork (TM). Pigment in the TM
is deposited in a homogenous pattern, unlike other entities that can cause TM pigmentation
(uveitis, exfoliation syndrome, melanoma, IOL-iris chaffing). Fine pigment granules can also
been seen on the anterior iris surface and the anterior lens capsule. Pigment liberation occurs
as a result of the posterior pigment epithelium of the iris rubbing against the crystalline lens
zonules. Slit-like transillumination defects (TID) will be seen in a radial pattern in the mid-
periphery of the iris when a bright light is shown through the pupil, best seen in a very dark room
in the slit lamp. Pigment liberation can also occur due to ocular trauma or surgery, but TI
defects will rarely be seen. The typical patient with PDS is a young, white male who is myopic
with a slightly concave iris posture. It is uncommon in persons with African or Asian ancestry,
but occurs in up to 2% of the Caucasian population. It appears to have incomplete penetration
by way of autosomal dominant inheritance.
PDS can lead to pigment dispersion glaucoma (PDG), which is a type of secondary open-angle
glaucoma. Conversion of PDS to PDG occurs in approximately 20% of PDS patients within 10
years of initial diagnosis. PDG is diagnosed when the classical triad of PDS is present
(Krukenberg spindle, iris trans-illumination defects, and trabecular meshwork
hyperpigmentation), along with progressive optic nerve cupping, glaucomatous visual field
changes, or ocular hypertension. Treatment should be begun if the IOP is elevated, even
without optic nerve degeneration or visual field abnormalities, to reduce the risk of future optic
nerve damage and vision loss.
ICD-9 CODES:
364.53 Pigment Dispersion Syndrome / Pigmentary Iris Degeneration / Translucency of
Iris
AEROMEDICAL CONCERNS: Peripheral retinal degeneration and retinal holes are significant
risk factors for retinal detachment, which can cause a painless, sudden loss of vision that may
permanently impact peripheral and central vision. Retinal degenerations are commonly seen in
highly myopic individuals and the increased risk of retinal detachment remains elevated even
after corneal refractive surgery is performed.
WAIVER: Any peripheral retinal degeneration or retinal hole is considered disqualifying (CD).
A diagnosis of “white without pressure” is a descriptive term for the appearance of the retina and
is Not Considered Disqualifying (NCD). Guidance for designated aviation personnel and
applicants are as follows:
INFORMATION REQUIRED:
1. Eye exam with DFE by Eye Care provider (Ophthalmology consult required for retinal
holes) with comment on long-term prognosis
2. Detailed retinal drawings or photographs
TREATMENT: Patient education and monitoring with a comprehensive eye exam, including
dilated fundus examination, is the most common course of action for patients with peripheral
retinal degenerations and retinal holes. Patients with retinal holes should be further evaluated
with scleral depression to ensure the stability of the hole and determine presence or absence of
shallow retinal detachment. Most small, stable holes are monitored annually, but may require
prophylactic laser treatment to reduce the risk of future detachment. Patients should be aware
of the signs and symptoms of retinal detachment, including an increase of flashing lights,
floaters, or blurry or obscured areas of vision beginning in the periphery. The patient should be
educated to return to the clinic for a repeat dilation immediately if they experience these
symptoms.
Thinning of the retina may lead to the formation of atropic holes or retinal breaks in 25% of
patients, but the frequency of retinal detachment as a result of retinal holes is low (3-14%).
Most atrophic holes do not require any treatment since they are not associated with vitreous
traction. However, upon discovery of atrophic holes, a consultation to an ophthalmologist is
indicated especially with patients who have high myopia, those who are active in contact sports,
or if there is a family or personal history of retinal detachment.
Retinal ‘white without pressure’ (WWOP) is an optical phenomenon in which vitreous traction
changes the retinal coloration upon examination. WWOP is usually bilateral and observed in
5% of patients over 20 years of age, but roughly 66% in patients over 70 ( 30% of the total
population). White without pressure is an incidental finding and there is no associated risk of
retinal holes, tears, or breaks with this condition.
ICD-9 CODES:
361.31 Round hole of the retina without detachment
362.60 Peripheral retinal degeneration, unspecified
362.61 Paving Stone Degeneration
362.63 Lattice Degeneration